<form action="." method="post" class="form-horizontal"><input type='hidden' name='csrfmiddlewaretoken' value='FDEwmyMzi4QO9R6BcCGshlLRKKdFCknA' />

            <div class="control-group">
                <label class="control-label" for="inputEmail">Введите IP-адрес</label>
                <div class="controls">
                    <input id="id_ip" name="ip" type="text" />

                </div>
            </div>

            <div class="control-group">
                <label class="control-label" for="inputCaptcha">Введите символы с этой картинки</label>
                <div class="controls">
                    <img src="/captcha/image/71bf0385689660663d33d32b100bfa64abd8a7b0/" alt="captcha" class="captcha" /> <input id="id_captcha_0" name="captcha_0" type="hidden" value="71bf0385689660663d33d32b100bfa64abd8a7b0" /> <br /><br /><input id="id_captcha_1" name="captcha_1" type="text" />

                </div>
            </div>

            <button type="submit" class="btn btn-primary">Проверить по базе</button>

        </form>